Background: This paper explores the various challenges that the health sector faces as corruption creeps into the sector. Objective: The research explains various review methods used to identify corruption and delineates anticorruption strategies appropriate to the health sector. Conclusion: The article concludes with suggestions for applied research needed to extend our understanding of corruption, and to help policymakers craft effective interventions. Given the fact that corruption is a chain reaction that traps millions in poverty and misery we have the social responsibility to take a stand on ethical practice. Further, the paper is a call to revise the Hippocratic Oath so as to include a clause against corruption in medical practice so that the saved individual, thanks to the treatment received, might not, along with the family, and be dragged into poverty which is just as life-threatening.

Corruption is defined by transparency international as “misuse of entrusted power for private gain.” Corruption occurs when officials, who have been given the authority to carry out goals for the public good, instead use their position, and power to benefit themselves and others close to them.[1],[2] Corruption is a pervasive problem affecting the health sector. At the level of individuals and households, there is mounting evidence of the negative effects of corruption on the health and welfare of citizens.[3],[4],[5],[6],[7]

Risks of corruption in the health sector are uniquely influenced by several organizational factors. The health sector is particularly vulnerable to corruption due to uncertainty surrounding the demand for services (who will fall ill, when and what will they need); many dispersed actors including regulators, payers, providers, consumers, and suppliers interacting in complex ways; and asymmetric information among the different actors, making it difficult to identify and control for diverging interests. In addition, the health care sector is unusual in the extent to which private providers are entrusted with important public roles, and a large amount of public money allocated to health spending in many countries.[2]

Types of corruption

The different areas where in corruption creeps in to the health sector are construction and rehabilitation of health facilities, purchase of equipment and supplies including drugs, distribution and use of drugs and supplies in service delivery, regulation of quality in products, services, facilities and professionals, education of health professionals, medical research, provision of services by medical personnel and other health workers.

As per transparency international, health has the maximum public interaction and is the second most corrupt sector. Corruption is ranging from indulging in unauthorized private practice to issuing medical certificates, transfers, postings, recruitment, in “tolerating” absenteeism, etc., Expensive hospital construction, high-tech equipment and the increasing arsenal of drugs needed for treatment, combined with a powerful market of vendors and pharmaceutical companies, present risks of bribery and conflict of interest in the health sector.[8],[9] The most sensitive areas are in the procurement of drugs and licensing of blood banks, where unlicensed manufacturers have been recipients of orders and action on spurious drug suppliers tardy. The pervasive spread of corruption is not limited to the public sector. The private sector is also working under low thresholds of integrity. Patients are exploited by being made to undergo unnecessary tests only for making money. Providers in private practice are seen to own pharmacies and diagnostic centers. They get “cuts” and commissions for referrals and such fee splitting is the mainstay of many doctors' monthly earnings. The health sector has been commercialized to an extent that it is unaffordable for the poor and the needy. There are adequate studies that have shown the disproportionately large number of cesarean sections of all deliveries in private hospitals. The rate of hysterectomies being performed among young women is one example of the absence of ethical standards that need to be effectively countered by fostering transparency, widening participation, strictly enforcing inspections and above all providing leadership in technical, administrative and political organizations in reiterating and reasserting value systems. Enforcing good management and governance is then absolutely essential since the implication of bad practices in the health sector hurts persons who are poor and suffer the double tragedy of being sick. No market can function or sustain itself unless there is a minimal level of integrity, fair play, and the rule of law. Therefore, if insurance and contracting the private sector are to be the new ways of expanding access and financing health, then it is essential that values of probity, nurturing of informed consumers, and wider participation through good governance be ensured.

The role of the health sector is to look after peoples' health and welfare. Drawing up legislation in a sector such as health is complex and requires an understanding of the incentives or disincentives such legislation may have on human behavior and a balanced approach. If the legislation is too inflexible and specific, putting all risks on the provider, then it may result in mindless litigation, increasing defensive medicine and higher costs for the patient, endanger the patient-doctor relationship which should be based on trust and entail harassment and outright corruption at the hands of the bureaucracy. If, on the other hand, it is too considerate to provider concerns, the patient may end up getting shortchanged. Besides, it is the enforcement of the laws that is more important. In some countries, inspectors and assessors sent to evaluate provider facilities for accreditation or licensing are trained, so that at all times the focus is on achieving the objective of increasing awareness and creating a sense of accountability among providers regarding the quality of patient care, and not the blind and mindless application of a standard or a rule. Thus, supervision needs to be supportive, not prescriptive or fault-finding, as the objective is not to drive away the providers but to persuade and convince them of the need to adhere to quality and patient safety. This calls for a different mindset to be cultivated through intensive training programs and performance monitoring systems. Supportive supervision is a new skill that needs to be nurtured in the health sector. The key challenge is the enforcement of regulations related to the “quack” or the unqualified practitioner in the villages. In a setting, where the public health system does not function, and the private sector is too expensive, it is this quack who enjoys social consent. Rational arguments of quality, harmful practices, or lack of qualification do not matter for the people as the quack can provide instant relief to a need at affordable cost. Good governance would require a political will to resolutely enforce discipline and make the public health system work, besides educating the people on the rational use of medical practices or drug use.

Measuring corruption

The first step in applying theory to practice is to measure corruption and the different mediating factors. While a number of assessment tools exist to help measure corruption and describe the circumstances in which it is found, there are several difficulties faced by researchers working in this field. First, the administrative systems in developing countries are often weak, making it difficult to collect measures of corruption such as unauthorized absences recorded in personnel records, or the percentage of procurements that did not meet standards. To overcome these difficulties, researchers have used indirect measures such as perceptions of corruption or procurement price data suggesting over-payment for supplies. Methods for measuring corruption in health systems include perception surveys, household, and public expenditure surveys, qualitative data collection and review of control systems.[10]

Conclusion

Corruption is a complex problem, which threatens health care facilities, services, and outcomes. Efforts to disaggregate specific corruption problems in the health sector and to identify and understand the root causes can help us face this difficult issue. It is also essential to train young health professionals with medical ethics. We can craft more effective programs to close off opportunities, alleviate pressures, and strengthen resistance to corruption. Transparency Act, consumer forums, patient management committees, village health committees, patients/citizens' charter, right to information, imparting of value systems and training in management practices, e-governance, redressal systems, etc., are some of the instruments that need to be employed by the government for counter-checking malpractice.